Pancreatico-pleural and bronchial fistulae and associated pseudocysts: case series.

CONTEXT: Pancreatico-pleural fistula is rare complication of chronic or acute pancreatitis. Previous studies have reported imaging features and various management options of this condition including conservative/medical management, endoscopic treatments and surgery.This article reviews the myriad of imaging appearances of this condition in multimodality imaging and different strategies for the successful management in a short case series. METHODS: After obtaining the institutional ethics committee approval, retrospective review of the medical records of five patients of pancreatico-pleural fistulae who were diagnosed and successfully managed in our hospital in 2012 and 2013 was done. Follow up with out patient records of these patients was also included.Findings were compared with the current available literature on this entity. RESULTS AND DISCUSSION: Pancreatico-pleural fistulae presents with massive pleural effusion.A high index of suspicion is essential for accurate diagnosis. Demonstration of the fistulous tracts requires cross sectional imaging with contrast enhanced CT being most commonly used and affords accurate diagnosis. MRI demonstrates the tracts and ductal disruptions with greater detail and are helpful in confirming the CT findings. Endoscopic ultrasound and ERCP also offer potential of diagnosis, although being technically demanding and invasive is reserved for interventions. Management of these conditions should be initially conservative with endoscopic stenting being offered in selected cases with favourable anatomy and not responding to conservative management. Surgery is reserved for cases not responding to conservative and endoscopic management. CONCLUSION: In conclusion this case series highlights the clinical and imaging spectrum of pancreatico-pleural fistulae and provides insight into the different management strategies that can be adopted for this condition.

Doppler sonographic evaluation of resistive index of intra-renal arteries in acute ureteric obstruction.

BACKGROUND: Acute ureteric colic is one of the most commonly encountered acute abdominal conditions. Diagnosis of obstruction caused by ureteric calculus occasionally becomes challenging if there is inadequate dilation of the urinary tract proximal to obstruction. In such a situation, intra-renal artery Doppler parameters can be used as a diagnostic tool. Our study compared intra-renal arterial Doppler in patients with obstructed and non-obstructed kidneys presenting within 24 h of onset of symptoms of unilateral acute renal colic. RESULTS: The resistivity index (RI) in the segmental arteries of all 54 patients with obstructed kidneys was significantly higher than in those with non-obstructed kidney: 0.75 vs. 0.56, with a p value less than 0.001, a sensitivity of 85% and a specificity of 93%. CONCLUSION: Doppler ultrasound is a useful diagnostic tool in the evaluation of acute renal obstruction, thus enabling practitioners to avoid ordering unnecessary CT and exposing patients to ionizing radiation. An RI value > 0.7 has good sensitivity and specificity in our study. The results obtained in the study were comparable to those of pioneer studies conducted worldwide.

Hereditary hemorrhagic telangiectasia of liver: Pathophysiology with role of radiology in diagnosis and treatment.

Hereditary hemorrhagic telangiectasia (HHT) or Osler-Weber-Rendu syndrome is a rare condition which can result in significant systemic and hepatobiliary abnormalities. Liver involvement in HHT consists primarily of the consequence of various intrahepatic shunts. Even though these vascular shunts are present in the majority of patients with HHT, symptoms occur only in minority with clear predilection to female gender. The symptoms and imaging findings of liver vascular malformations can be easily overlooked or misdiagnosed which can result in delay in treatment or potentially harmful vascular interventions. In this case report, we discuss the pathophysiology of HHT in liver involvement, role of imaging in diagnosis, and the possible role of interventional radiologist in the treatment.

Miliary Sarcoidosis: does it exist? A case series and systematic review of literature.

BACKGROUND AND OBJECTIVES: Sarcoidosis typically presents with peribronchovascular and perilymphatic nodules on high-resolution computed tomography (HRCT); a miliary pattern is reported but not well described. DESIGN SETTING: We describe four patients with miliary sarcoidosis and results of a systematic review of all previously reported cases from 1985 onwards. RESULTS: We identified only 27 cases of "miliary" sarcoidosis in the HRCT era. These patients were older (85.2% older than 40 years), had more co-morbidities (72.7%) and were symptomatic compared to "typical" sarcoidosis. Respiratory symptoms were present in 61.9% at diagnosis. Hypercalcemia was seen in 28.5%. On review of HRCT images, only 34.6% (9/26) had a "true miliary" pattern without fissural nodules. In our series, prominent perivascular granulomas were seen on histopathology in all. 44.4% (12/27) had tuberculosis preceding or concurrent to miliary sarcoidosis. Of the eight true associations, tuberculosis preceded sarcoidosis by 52 (median, IQR 36) weeks in six and occurred concurrently in another two. The diagnosis of tuberculosis was clinical in all with concurrent diagnosis of tuberculosis and sarcoidosis. Treatment with steroids had 100% response and 14.2% relapse. CONCLUSIONS: A true miliary pattern in the HRCT era is very rare in sarcoidosis and subtle perilymphatic pattern is nearly always seen; this should be labeled "pseudo-miliary". Prominent perivascular granulomas are associated with true miliary pattern. Miliary sarcoidosis patients are older and symptomatic, needing treatment at diagnosis. "Miliary" sarcoidosis may follow treatment for tuberculosis; concurrent cases possibly indicate the difficulty in differentiating both or a "tuberculo-sarcoid" presentation. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (1): 53-65).

An unusual cause of breathlessness and profuse micronodules.

We describe a 21-year-old male with a history of smoking and subacute onset of breathlessness with normal cardiorespiratory examination. The presence of "track marks" and digital infarcts prompted evaluation for infective endocarditis and confrontational history taking revealed anorexia, weight loss over 3 months along with intravenous drug abuse of reconstituted tablets of tapentadol. Echocardiography was normal and blood cultures were sterile; computed tomography showed bilateral, diffuse, small centrilobular nodules with "tree-in-bud" appearance. In this clinicopathologic conference, we discuss the clinical and radiological differential diagnosis of centrilobular nodules, lung biopsy findings, and management options for patients with such a presentation.

Magnetic resonance imaging brain findings in a case of aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder, presenting with intractable vomiting and hiccups.

Neuromyelitisoptica (NMO) and multiple sclerosis (MS) were once considered to be differing manifestation of same auto immune disease, NMO predominantly involving the optic nerve and cord. Now with discovery of NMO antibody the concept has changed and a spectrum of disorders with lesions in brain has been identified. Occasionally, brain may be the first or the only site of involvement in these disorders hence it is essential to be aware of this spectrum. The brain lesions in NMO/NMOSD may be located in characteristic regions and present with symptoms mimicking non neurological disease. We herein present a case of an adult female who was admitted with intractable vomiting and hiccups; subsequently on MRI brain found to have very tiny demyelinating foci in Area Postrema.

Chronic pancreatitis presenting with pseudocyst of pancreas and pseudo-aneurysm of hepatic artery.

A 2-y-old girl presented with recurrent abdominal pain and hematemesis. The patient was diagnosed to have chronic calcific pancreatitis complicated by pseudocyst of the head of pancreas and pseudo-aneurysm of the common hepatic artery. Diagnosis was made using abdominal ultrasonography and CT angiography. The rarity of the presentation of pseudocyst with pseudo-aneurysm formation in a pediatric patient is noted. The pseudo-aneurysm was treated by embolization of the artery and the pain being refractory to analgesics was managed by celiac plexus blockade.